Nutrition Recommendations and Interventions for Diabetes

Position Statement of the American Diabetes Association
American Diabetes Association
Coronary artery disease in patients with coronary artery disease, chronic kidney disease, chronic cardiovascular disease, renal disease, cardiovascular disease, the DPP, the Program Diabetes Prevention, the Food and Drug Administration (FDA), gestational diabetes, diabetes gestational maternal and newborn infant tetanus, USDA, FDA medical nutrition therapy RDA recommended intake of U.S. Department of Agriculture
Medical nutrition therapy (MNT) is important in the prevention of diabetes, management of existing diabetes, and prevent or at least delay the development rate of complications of diabetes mellitus. Therefore, it is important in the prevention of diabetes at all levels (see Table 1). MNT is an integral part of diabetes self-management education (training). This statement provides evidence-based recommendations and tetanus intervention maternal and neonatal diabetes. Previous consensus regarding the technical review published in 2002 (1), and minor modifications, 2004 (2). This statement updates the previous statement of position, to focus on the main reference literature since 2000, and classified according to the evidence, according to the American Diabetes Association evidence level rating system. Closely linked due to overweight and obesity, diabetes, and pay special attention to this aspect MNT.

The purpose of these recommendations is to make patients with diabetes and healthcare professionals who recognize beneficial nutritional interventions. Considering the treatment objectives, strategies to achieve these objectives and to change individuals with diabetes is willing and able to make the need to use the best available scientific evidence. Nutrition-related goals requires a coordinated team effort, including people with diabetes, including its decision making process. It recommended that a registered dietitian, MNT, team members play a leading role in providing nutrition and health knowledge and skills. However, it is important that all team members, including doctors and nurses, and understanding of maternal and neonatal tetanus, and support their implementation.

MNT, as shown in Table 1, has played an important role in the three levels related diabetes specific prevention U.S. Department Health and Human Services. Primary prevention interventions attempt to delay or prevent the development of diabetes. This relates to public health measures to reduce the prevalence of obesity and people with pre-diabetes, including maternal and neonatal tetanus. Interventions are secondary and tertiary prevention: MNT people suffering from diabetes, and seek to prevent (two) or control (three) the occurrence of diabetic complications.


The following section
The MNT, the aim of prevention and treatment of diabetes

By destination MNT applicable to persons at risk for diabetes or pre-diabetes
To reduce the risk of diabetes and cardiovascular disease (CVD), the promotion of healthy food choices and physical activity, maintaining a moderate weight loss.

MNT Personal goal for people with diabetes
) To achieve and maintain

The blood glucose levels within the normal range, or near normal, safe can

Lipids and lipoproteins, reducing the risk of vascular disease

Pressure levels in the normal range or close to normal, you can be sure

) To avoid or at least decrease the development of chronic complications of diabetes, by modifying nutritional intake and lifestyle rate

) In order to meet the nutritional needs of people, taking into account personal and cultural preferences and willingness to change

) In order to maintain the pleasure of eating, the only restrictions on the choice of food when the scientific evidence that

A MNT objective applicable to the case,
) In adolescents with type 1 diabetes, patients with type 2 diabetes adolescents, pregnant women and nursing mothers, the elderly, people with diabetes to meet the nutritional needs of these unique life cycle.

) With insulin or insulin secretagogues agents work for the behavior of security personnel, including hypoglycemia, diabetes self-management training treatment of acute disease prevention and treatment.

The
The following section
Effectiveness of MNT

Proposal
People with pre-diabetes or diabetes should receive individualized MNT by a registered dietitian familiar with diabetes MNT part of this treatment is best. (B)

Nutrition counseling should be sensitive to individual needs, readiness to change and the ability to make a change in people with pre-diabetes or diabetes. (E)

Clinical trials / studies report results MNT 1% of type 1 and type 2 diabetes in the 1-2% decrease in glycosylated hemoglobin (A1C), duration of diabetes (3,4). Meta-analysis of non-diabetics, free life issues and the report of the Committee of Experts MNT lowering low-density lipoprotein cholesterol 15-25 mg / dl (5.6). Improvement of 3-6 months after the start of the MNT, obviously. Meta-analysis also supports the role of lifestyle change in the treatment of hypertension (7.8) and the Committee of Experts.

The
The following section
Energy balance, overweight and obesity

Proposal
Individuals weight loss overweight and obesity, insulin resistance, and has modest shown to improve insulin resistance. Therefore, all these people or risk of diabetes, weight loss is recommended. (A)

For weight loss, either low-carbohydrate diets or low-fat calorie-restricted may be effective in the short term (one year). (A)

For patients with low-carb diet, monitoring blood lipids, renal function, protein intake and kidney disease and adjust hypoglycemic therapy. (E)

The important part of weight loss program, physical activity and behavior modification, and is very helpful in maintaining weight loss. (B)

Weight loss drugs can be considered the treatment of overweight and obese patients with type 2 diabetes and can help reach 10.5% by weight of changes in the style of losses. (B)

Weight loss surgery may be considered for the treatment of type 2 diabetes in patients with BMI ≥ 35 kg/m2 for some people, it can lead to a significant improvement of blood glucose. Bariatric surgery continue to study the long-term benefits and risks in people with pre-diabetes or diabetes. (B)

The importance of weight control is very important in reducing the risk of diabetes-related. Therefore, these nutritional advice to first consider the energy balance and weight loss strategies. The guidelines of the National Heart, Lung and Blood overweight, BMI ≥ 25 kg/m2, and obese BMI ≥ 30 kg/m2 three (9). The risk of complications associated with excess adipose tissue increased within this range, BMI above. However, clinicians should be aware that, in some Asian populations, the proportion of people at high risk for type 2 diabetes and cardiovascular disease is important BMI> 23 kg/m2 (10). Visceral fat body, measuring waist circumference ≥ 35 cm in women and men ≥ 40 inches, with the body mass index to assess the risk of type 2 diabetes and cardiovascular disease (Table 2), and (9 ). Small cutoffs of waist circumference (≥ 31 cm in women ≥ 35 cm in men) may be appropriate for Asian populations (11).

Because of the impact of obesity on insulin resistance, weight loss is an important therapeutic target individuals with diabetes or pre-diabetes (12). However, long term weight loss is difficult for most people to complete. This is probably because the central nervous system plays an important role in the regulation of energy intake and expenditure. Short term studies have demonstrated that moderate weight loss (5% of body weight) of subjects with type 2 diabetes and reduce insulin resistance, glucose and lipids improvements and lower blood pressure (13). More long-term (≥ 52 weeks), the use of drugs in adult patients with type 2 diabetes lose weight generate appropriate to reduce weight and A1C (14), A1C no improvement in all studies (15, 16). Looking to the future (health action to diabetes) is a major national health institutions funded clinical trial to determine whether long-term weight loss improve blood sugar and prevention of cardiovascular events (17). Is completed, the study gives a weight loss of long term important clinical outcomes.

There is evidence that structured programs, intensive lifestyle involving participation in education, personalized guidance, reducing the total energy intake of dietary energy and fat (30%), regular physical activity and often involved contact necessary to produce long term weight loss of 5 to 7% of the initial weight (1). The recent review of the role of weight and control type 2 diabetes, the lifestyle changes (13). Although structured lifestyle has effectively delivered when funded clinical trials, should be implemented clinical outcome is not clear. The interventions of the organization, delivery, capital and other lifestyle are issues that must be addressed. The third party payment may not be sufficient to provide an adequate frequency and time benefits MNT, to achieve the purpose of weight loss (18).

Exercise and physical activity alone, only modest weight loss. However, exercise and physical activity should be encouraged, because they improve insulin sensitivity, weight loss, severe hypoglycemia, weight loss (1) long-term maintenance is very important. Lose weight with behavioral therapy has been mild, and behaves as a weight loss strategy auxiliary can be the most useful.

Weight Loss Diet Standard 500-1000 calories less than estimated as needed to maintain body weight, initially caused a loss of about 1-2 pounds / week. While many people can lose some weight to six months of initial weight (up 10%), as a diet, if not continue to support and follow up, people usually recover lost weight.

The best macronutrient distribution of the diet weight loss has not been established. Despite the traditional low-fat diet to promote weight loss, two randomized controlled trials of subjects found that low-carbohydrate diet lost more weight as compared to the low fat diet for 6 months (19, 20) . Another study showed that overweight women were randomly assigned to four weight loss diets significantly higher in the 12 months the Atkins low-carbohydrate diet with a high carbohydrate diet (20A). However, once again, the difference between low carb and low-fat weight loss does not significantly moderate diet and lose weight. The most favorable changes in serum triglycerides and high-density lipoprotein cholesterol, low-carbohydrate diet. In one study, subjects with type 2 diabetes showed a greater reduction in A1C with a low-carbohydrate diet than a low-fat diet (20). A recent meta-analysis of the results showed greater improvement in six months, high-density lipoprotein, triglycerides and cholesterol than low-fat, low-carbohydrate diet, but in the low-carb diet carbon (21) of low density lipoprotein cholesterol were significantly higher. More research is needed to determine the efficacy and long term safety of low-carbohydrate diet (13). The recommended dietary allowance (RDA) of 130 g of digestible carbohydrate / day, and in accordance with the fuel required in the central nervous system, does not provide sufficient glucose-dependent protein or fat intake of glucose production (22) . A long-term metabolic effects of a very low carbohydrate diet low carbohydrate diet, brain fuel needs can be met is unclear, this diet eliminates many important sources of energy, fiber, vitamins and minerals in foods and is important in the diet of Palatability (22).

The meal replacement products (liquid or solid pre-packaging) to provide a certain amount of energy, usually formulated products. Use meal replacement once or twice a day, usually can result in significant weight loss meal replacement. Meal replacement weight loss program is the future, (17) is an important part. However, dietary replacement therapy should be continued, if desired maintain weight loss.

Very low calorie, ≤ 800 calories daily and produce large amounts of weight loss and rapid improvement of blood glucose and blood lipids in patients with type 2 diabetic subjects. When the top and self-selection of meals is a very low calorie diet, weight regain is common. Therefore, it seems that there is a very low calorie diet in the treatment of type 2 diabetes limited usefulness and should be considered only in conjunction with a weight loss program structured.

Available data suggest that weight loss drugs can be useful, can help overweight people in the treatment of type 2 diabetes risk, and achieve a weight loss of 10.5% and changes in lifestyle ( 14). According to their labels, these drugs should only be used for diabetes BMI> 27.0 kg/m2 people.

Stomach reduction surgery for the treatment of weight loss, obesity and diabetes in patients with a BMI ≥ 35 kg/m2 being considered. A meta-analysis of bariatric surgery reported that 77% of patients with type 2 diabetes a complete solution, 86% of diabetes (normalization of glucose levels in the blood) and in the case of diabetes therapy medications to solve or improve staff (23). Accepting weight loss surgery, a 10-year follow-up study of obesity in Sweden, 36% of subjects with diabetes resolution matched control group (24) in comparison with 13% of diabetes. All risk factors of cardiovascular diseases, in addition to the improvement of hypercholesterolemia in surgery patients.

The
The following section
Nutrition recommendations and interventions for diabetes prevention (primary prevention)

Proposal
Emphasize lifestyle changes, including moderate weight loss (7% body weight) and regular physical activity (150 minutes / week), with dietary strategies such as calorie intake in the diet in people with high risk for type 2 diabetes, a systematic plan to reduce fat intake, you can reduce the risk of diabetes, are recommended. (A)

Should encourage individuals in high-risk patients with type 2 diabetes, the United States Department of Agriculture (USDA) recommended (14 g fiber / 1,000 kcal) dietary fiber and foods containing whole grains (half of the intake grain). (B)

It is not sufficient and consistent information to conclude that: low glycemic load diet reduces the risk of diabetes. However, low glycemic index foods, rich in nutrients, fiber and other important and should be encouraged. (E)

Observational studies suggest that moderate drinking may reduce the risk of diabetes, but the data does not support the use of alcohol in the proposal of individuals at risk of diabetes. (B)

No nutritional advice can prevent type 1 diabetes. (E)

Although there are insufficient data to ensure that the specific recommendations for the prevention of type 2 diabetes in young people, which is reasonable, the applicable method proven effective in adults, nutritional needs, always maintaining growth and development normal. (E)

Prevention of type 2 diabetes, emphasizing the importance of a substantial increase in recent years, the prevalence of diabetes in the world. Genetic predisposition appears to play an important role in the incidence of type 2 diabetes. However, with the passage of time, the speed of transfer of the gene pool of the population is very slow, the current epidemic of diabetes may reflect a change in lifestyle lead to diabetes. Seems to have come together to promote lifestyle changes, increased energy consumption, reduced physical activity overweight and obesity, diabetes risk factors is powerful.

Some studies suggest that the potential loss of mild, lasting weight significantly reduce the risk of type 2 diabetes, and whether or not you lose weight is through lifestyle changes or adjuvant therapies (such as medication or bariatric ( see energy balance Festival) (1)). Also, two moderate exercise and vigorous may improve insulin sensitivity independent of weight loss, reduce the risk of diabetes type 2 (1).

From the Finnish Diabetes Prevention (25) and (26) in the Diabetes Prevention Program (DPP) clinical trial data strongly support modest weight loss, in order to reduce the possible risk of type 2 diabetes . Lifestyle intervention in the two trials, the emphasis on lifestyle changes, including moderate weight loss (7% body weight) and regular physical activity (150 minutes / week), with dietary strategy to reduce consumption of fats and calories. DPP participants in the lifestyle intervention group dietary fat intake to 34% of energy is 1 year after the intervention (27) at baseline and 28% of energy. Most subjects in the lifestyle intervention reached 150 minutes / week of moderate physical activity (26, 28) of the physical activity goal. In addition to prevention of diabetes, lifestyle intervention to improve cardiovascular risk factors DPP, including dsylipidemia, hypertension and inflammatory markers (29,30). DPP analysis shows that the cost-effectiveness of lifestyle intervention (31), but other tests show that the expected cost reduction (32).

Study Finnish Diabetes Prevention and DPP focused on reducing calorie intake (dietary intervention to reduce fat in the food). It is worth noting that, to reduce the intake of fat, particularly saturated fat may reduce the risk of diabetes by improving insulin resistance (1,33,34) independent energy production and promote the loss of weight. Reducing other macronutrients (carbohydrates), it is possible, but also effectively prevent diabetes, but to promote the effectiveness of weight loss low carb diet for type 2 diabetes prevention data main clinical trials do not provide .

Some studies provide evidence that it can reduce the risk of diabetes and increase whole grains and dietary fiber intake (1.35 to 37). Improve insulin sensitivity, independent of body weight and contains whole grain foods, dietary fiber has been associated with improved insulin sensitivity and enhanced insulin secretion capacity fully overcome insulin resistance (38). Controversial potential role in the prevention of type 2 diabetes, the glycemic index and low glycemic load diet. Although some studies have shown that the association between glycemic load and the risk of diabetes, other studies have failed to confirm this relationship, a new report shows not associated with glycemic index / glycemic load and insulin sensitivity (39).

Therefore, there is insufficient information and consistent, came to this conclusion: the diet of low glycemic load to reduce the risk of diabetes. Prospective randomized clinical trials to address this problem is necessary. However, low glycemic index foods, rich in nutrients, fiber and other important and should be encouraged. The statement of the American Diabetes Association in 2004, in a thorough review of this issue, (40), and the carbohydrate portion of this document in more detail and glycemic load l glucose in diabetes management related issues have been resolved.

Observational studies have shown that moderate alcohol consumption (three drinks [15-45 grams of alcohol per day) UJ association between reduced risk of type 2 diabetes (41, 42), coronary heart disease (CHD) (42 43 ), and stroke (44). However, the alcohol (greater than 3 drink one day) can increase the incidence of diabetes (42). If drinking from the recommendations of the USDA 2005 Guidelines for Americans diet, it is recommended that no more than a day to drink a glass of wine, women and men, two drinks a day (45).

Micronutrients selected may affect glucose and insulin metabolism, until now, no convincing data, recorded their role in the development of diabetes.

Juvenile Diabetes
No nutritional recommendations at this time (1) prevention of type 1 diabetes. The increase appears to increase the prevalence of type 2 diabetes, especially in young minority adolescents are overweight and obese. Although data are not sufficient to guarantee specific recommendations for youth with type 2 diabetes, preventive interventions proven effective in preventing type 2 diabetes in adults (lifestyle changes, including reducing energy intake and regular physical activity) is can be beneficial. Children in ongoing clinical trials of this intervention.

The
The following section
Nutritional recommendations for the treatment of diabetes (secondary prevention)

Carbohydrates recommendations for the management of diabetes
Promoting healthy eating habits, carbohydrates, including fruits, vegetables, whole grains, legumes, low-fat milk. (B)

Carbohydrates monitoring, carbohydrate counting, exchanges, or estimates based on experience remains a key strategy to achieve glycemic control. (A)

In observation, total carbohydrates is the glycemic index and load may be used only to provide a small amount of additional advantages. (B)

Sucrose-containing foods can be substituted for another diet plan carbohydrates, if you add a meal plan, which includes insulin or other hypoglycemic drugs. Care should be taken to avoid excessive energy intake. (A)

In the general population, people with diabetes to encourage eating a variety of foods that contain fiber. However, the lack of evidence, the increased intake of fiber recommended for people with diabetes than the population as a whole. (B)

Sugar alcohols and non-nutritive sweeteners are safe when consumed within the level of daily intake by the Food and Drug Administration (FDA). (A)

In efforts to achieve levels of normal or near normal glycemic control is a major goal of diabetes management. Food and nutrition interventions to reduce postprandial glucose tour is very important in this regard, because the major determinants of dietary levels of postprandial glycemic carbohydrates. Low carb diets seem to be a logical way to reduce postprandial glucose. However, foods containing carbohydrates are an important source of energy, fiber, vitamins, minerals and dietary palatability is very important. Therefore, these foods are an important part of the diet of people with diabetes. Carbohydrates and the problem of blood sugar was above an extensive review, the report from the American Diabetes Association, and nutritional counseling to the general public (1,2,22,40,45).

After meal blood glucose concentrations of glucose in the bloodstream (digestion and absorption) and the appearance of the gap loop (40) depends primarily on the rate. The secretory response of insulin to maintain normal blood glucose within a narrow range, but in individuals with diabetes, defects in insulin action, insulin secretion, carbohydrates or postprandial glucose control diet damage. The number and type, or content in the blood glucose level postprandial carbohydrate source in the food.

Number and type of carbohydrate.
ADA Statement 2004 analyzes the impact of the number and type of diabetes (40) of carbohydrates. As mentioned above, the RDA carbohydrates (130 g / d) (22) is half of the minimum requirements. No assays, particularly in patients with diabetes limit of <130 g / day of total carbohydrates. However, the 1-year follow-up test data from a small weight loss (20) indicates that the subgroup with diabetes, fasting blood glucose is, is reduced to 21 mg / dl (1.17 mmol / l) and 28 mg / dl (1.55 mmol / l) of the low-carb, low-fat, no significant differences in changes in glycosylated hemoglobin levels. 1-year follow-up data also showed that, compared to carbohydrate intake (mean intake 230 and 120 grams) macronutrients different treatment group. Therefore, the uptake and metabolism of long-term effects and safety, more research is needed.

Carbohydrate intake is usually the main determinant of the postprandial response, but the type of carbohydrates, which also affect the response. The intrinsic variables affect the effect of carbohydrate-containing meal glycemic response, including a specific type of food intake, the type of starch (amylose and amylopectin), style preparation (cooking method and time, the heat or moisture amount), mature, and the degree of processing. External variables can affect the glycemic response include fasting blood levels of glucose or food intake of dietary macronutrient distribution available insulin and insulin resistance.

The glycemic index of food has been developed in order to compare the different postprandial carbohydrate containing food (46) a constant quantity of the reaction. The glycemic index of a food is more than 2 hours of fasting blood glucose in the area constant amount of food intake (typically 50 g portion of carbohydrate) response divided by a reference food (usually after that increased glucose or white bread). The glycemic load meals and diet method of calculation is the amount of carbohydrates glycemic index multiplied by the ingredients of the food, then at each total food value of all foods. Low glycemic index include oats, barley, wheat, beans, lentils, beans, pasta, rye bread thick black wheat, apples, oranges, milk, yogurt, ice cream. Dietary fiber, fructose, lactose, fat component, tend to reduce the glycemic response. Methodological issues (47) has noted the potential and the glycemic index.

Randomized clinical trials that reported low-glycemic index diet to lower blood sugar in diabetic patients, but other clinical studies have not confirmed this effect (40). Furthermore, in response to a specific variation of the carbohydrate-containing food is a concern (48). However, a recent meta-analysis of trials of low-glycemic index diet for diabetics show that this diet reduces by 0.4% in A1C compared with high glycemic index diet (49). However, it seems that most people already eat a diet with a moderate glycemic index (39.50). Therefore, it seems that in the personal consumption of high glycemic index diet, control of postprandial hyperglycemia low glycemic index diet will produce moderate benefits.